Appeals Manager Resume Samples

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H Abernathy

Henri

Abernathy

749 Myles Stravenue

Dallas

+1 (555) 971 7383

749 Myles Stravenue

Dallas

Phone

p +1 (555) 971 7383

Experience Experience

Philadelphia, PA

Appeals Manager

Philadelphia, PA

Bradtke, Schiller and Gislason

Philadelphia, PA

Appeals Manager

Oversee daily operations of multiple levels of staff and multiple functions across one or more business units
Provide expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims
Conduct data entry and re-work; analyzes and identifies trends and provides reports as necessary
Lead project management and implementation initiatives
Impact of work is most often at the local level
Identifies continuous quality improvement measures through appeal result analysis while partnering with the operations team ensuring best practices are met
Monitors changes to the ERISA legislation; incorporates workflow changes into the process as defined in legislative changes

Philadelphia, PA

Manager, Medicare Advantage Appeals

Philadelphia, PA

Boyer-Jast

Philadelphia, PA

Manager, Medicare Advantage Appeals

Conducts all auditing activities for assigned area; trends appeals and facilitate meetings to review data for process/product improvements
Collaboration with Highmark’s Provider Network
Collaboration within interdepartmental work groups i.e. Care Management Systems, Provider Services, Medicare C&D Compliance, Pharmacy, Quality Improvement, Product staff, Provider Reimbursement and Contracting
Actively involved in MM&P and MA Appeals operational performance in relation to monthly STARS results. Critical responsibility to achieve maximum STARS ratings which has financial impact to Highmark, Inc is to conduct tracking, trending and process improvement for operational processes that impact STARS performance
Identify, develop, and implement division/department projects which are focused on quality, utilization, process and/or outcome improvements. Identify industry benchmarks through scientific research and literature searches on order to assure Medical Management & Policy exceeds industry standards
Collaboration with interdepartmental work groups i.e. Compliance and Quality, Operations and Physician Advisors
Other duties as assigned or requested

present

Philadelphia, PA

Manager of Denials & Appeals

Philadelphia, PA

Pagac, Ondricka and Heidenreich

present

Philadelphia, PA

Manager of Denials & Appeals

present

Collaborates with Finance, revenue cycle personnel, physicians, contracting team, case managers, and payers to appeal denials and mitigate trends
Keeps up-to-date on issues surrounding commercial and government payer regulations and processes around audits and denials, and implementing policies and procedures to assure compliant and accurate billing practices
Develop and track indicators and report trends to Director and CFO. Provide feedback to department regarding changes in third party expectations as well as any trends in denial activity
Responsible for analyzing and interpreting trends associated with denials and appeals to effectively manage reimbursement and build strategies for mitigating future denials
Perform prebill audits on all inptatient stays that do not meet the 2 midnight rule and assure the proper level of care. Notify finance of outcome of audit
Perform retrospective record reviews providing clinical updates to insurer in a timely manner. Utilize written and verbal exchange of clinical information for the purpose of providing clear, unambiguous clinical review to payer for purposes of payment determination
Serve as a resource to Finance, Patient Access, Coding, Patient Accounts and various clinical departments in clarifying hospital status for specific accounts. Stays concurrent on and provides education on regulatory changes as it relates to level of care determination, discharge planning, and appeals and denials

Education Education

Bachelor’s Degree in Nursing

Quinnipiac University

Bachelor’s Degree in Nursing

Skills Skills

Excellent knowledge of disability claims management practices
Strong organizational skills and attention to detail
Ability to build professional relationships
Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems
Ability to work in a team environment
Able to work well individually, in teams and work virtually
Communication - communicates clearly and concisely, verbally and in writing. This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately. The ability to communicate with staff, Parallon Management, Division and Group Executives
Excellent negotiation skills
Interpersonal Skills - able to work effectively with other employees, patients and external parties
Leadership - guides individuals and groups toward desired outcomes, setting high performance standards and delivering leading quality services

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12 Appeals Manager resume templates

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Appeals Manager Resume Examples & Samples

10+ years in Housing Programs with emphasis on Disaster Recovery
Strong analytical, quantitative, problem-solving and decision making capabilities
Ability to prioritize and multi-task in a fast-paced environment
Able to work well individually, in teams and work virtually

PDP Appeals Manager Resume Examples & Samples

Progressive operational experience in a formal or informal leadership role
Leadership experience over a large metric-intensive operational unit
Proficient in Microsoft Applications
Certification with SixSigma and/or the Project Management Institute is very helpful
Grievance and appeals experience

Case Manager Appeals Resume Examples & Samples

Education: Bachelors, Associate Degree or diploma in Nursing
Experience: 3 years clinical experience. Experience in Case Management, Quality Management and/or Appeals Management preferred
Licensure: Current RN license, State of Michigan

Grievances & Appeals Manager Resume Examples & Samples

Fully bilingual English/Spanish
Strong computer skills including MS Office desktop applications (Word, Excel, PowerPoint, Visio, Project)
Demonstrated competency in both oral and written communication skills
Proven knowledge in Medicare regulations

Senior Manager Medicare Appeals & Grievances Resume Examples & Samples

Oversight and manage approximately 100 appeals staff in the US, including global partner performance
Monitor inventory, productivity, timeliness, quality and ensure CMS regulatory requirements are met. (Responsible for 10,000+ pieces of correspondence per day)
Analyze and troubleshoot variances in inventory and proactively take action plans to address variances
Manage the organization utilizing the principles and processes of the United Operating Model
Manages appeals and grievances (Medicare)
Attend multiple meetings and present to multiple levels of management. Be able to articulate solutions to issues for management
2 + years of operational experience with inventory or call volume management experience
2+ years of management experience with increasing responsibility
Proficient Microsoft Word, Excel, PowerPoint and keyboarding skills
Prior experience with Medicare claims or Appeals and Grievances or CTMs
Demonstrated ability to provide constructive feedback and developmental coaching in a clear and respectful manner
Experience in identifying opportunities for customer improvement and process efficiencies
Effective at establishing strategic plans and objectives to ensure operational discipline, operational effectiveness and operational execution
Experience managing employees from multiple office locations as well as work from home employees
5+ years of Medicare, Medicaid or Commercial Health Insurance experience
5+ years of operational experience with inventory or call volume management experience
Experience working with vendors and employees in India
2+ years of root cause analysis and research (i.e., Six Sigma experience)
Demonstrated experience in taking initiative in making decisions and taking action to delivery on required outcomes
Effective verbal / written communication skills; (i.e. Effective verbal / written communication skills; as you will be responsible for speaking with business partners and internal leadership regarding federal level compliance, requirements, and improvement plans

Appeals & Grievance Manager Resume Examples & Samples

Understand and apply all CMS, State and Client requirements related to grievances and appeals as well as company policies related to benefit administration for all lines of business
Manage team of staff working appeals & grievances and develop/maintain necessary training programs on relevant CMS, State, and Health Plan requirements
Create & Maintain A&G policies, processes and procedures, and workflows. Ensure data for CMS, State and other regulatory reports and data validation audits is accurate and complete
Supervise the creation, maintenance, and communication of dashboards of appeals and grievances received, status and resolution
Develop the necessary reporting infrastructure to identify and trend A&G incidents and partner with cross-functional business partners to resolve upstream root causes
Participate in relevant cross-functional committees, including those charged with making determinations regarding exceptions to standard policies, Compliance oversight, and Stars
Maintain confidentiality of member, physician and employee information
Foster strong professional working relationships with others in the company, delegates and external agencies to aid in the implementation of cross-functional cooperation and improvement of interdepartmental processes
Represent Prominence Health in a courteous manner in attitude and appearance, behaving ethically and using a professional demeanor in oral and written communications with internal and external customers
Adhere to all company compliance standards
8+ years of progressive industry experience in appeals & grievance, customer service, health plans, managed care, provider relations, and/or utilization management
Prior experience working in Medicare Part C and D appeals strongly preferred
Established track record of managing staff working under tight deadlines
Must possess strong team management, problem-solving skills, project management and negotiation skills and have the ability to multi-task in an effective and organized manner
Ability to establish and maintain good working relationships with staff, external customers and government agencies, as necessary
Solid understanding of claims payment and care management systems, general health plan operations, and benefit plans
Understanding of government billing regulations, including; State DOI rules, Medicare Managed Care, and Medical Terminology

Manager, Grievance / Appeals / Denials Resume Examples & Samples

SharePoint
Facets
Macess
Pega Appeals
RN, LPC, or LCSW license

Appeals Manager Resume Examples & Samples

Customer Orientation- establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
Interpersonal Skills - able to work effectively with other employees, patients and external parties
PC Skills- demonstrates proficiency in Microsoft Office applications and others as required
Tactical Execution - oversees the development, deployment and direction of complex programs and processes
Project Management - assesses work activities and allocates resources appropriately
Basic Skills- demonstrates ability to organize, perform and track multiple tasks accurately in short timeframes, have ability to work quickly and accurately in a fast-paced environment while managing multiple demands, ability to work both independently and collaboratively as a team player, adaptability, analytical and problem solving ability and attention to detail and able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
Minimum three years’ experience in related area with two of these years being healthcare management experience OR completion of the Parallon Manager Trainee Program

Manager Denials & Appeals Resume Examples & Samples

Current, unencumbered license to practice as a Registered Nurse
Five (5+) years’ home health experience
Three (3+) years’ management experience
One (1+) year denials and appeals experience
Knowledge of updated coding compliance guidelines, coding clinic references and CMS regulations
Certification in OASIS and HCS-D coding within first nine (9) months in position

Manager, Appeals & Grievances Resume Examples & Samples

Manages staff responsible for the submission/resolution of Provider inquiries, appeals and grievances for the Plan. Ensures resolutions are compliant
Proactively assesses and audits business processes to determine those most effective and efficient at resolving Provider problems
Serves as primary interface with Corporate Claims and Configuration counterparts and ensures standard processes are implemented
Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements
Maintains call tracking system of correspondence and outcomes for Providers appeals/grievances; oversees monitoring of each member submission/resolution to ensure all internal and regulatory timelines are met
Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing)
6+ years experience in healthcare claims review and/or member dispute resolution; supervisory or management experience

Appeals Manager Resume Examples & Samples

Minimum 3 years management experience preferably in a multi-site/multi-state environment
Must have a Financial/Accounting, Clinical Appeals, and/or Hospital Revenue Cycle background
Ability to articulate problems/claim issues to insurance provider reps clearly and be able to collaborate with them, and HCA contracting, to resolve
Background interacting with Hospital Case Mgmt and/or involvement in Utilization Mgmt process a plus (understanding of prior authorization process)
Ability to Identify Trends
Ability to build and maintain internal and external relationships
Solid written and oral skills
Proven track record of inventory management and account resolution
Proven track record managing staff productivity and quality
Proven track record of successful process improvement in account resolution
* ONLY CANDIDATES WITH SALARY REQUIREMENTS LISTED WILL BE CONSIDERED**

NV MCD Manager, Grievance & Appeals Resume Examples & Samples

Direct experience processing Medicaid or Medicare Grievances and Appeals
5 years’ experience as a Grievance and Appeal Analyst, or 3 years’ experience as a; Sr. Grievance and Appeal Analyst, Grievance and Appeal Consultant, Grievance or Appeal Supervisor/Manager
Experience with operations or project management a plus
Knowledge of ICD-9 and CPT codes desired
Data Management experience required
Experience implementing regulatory requirements and understanding of state and federal laws
Previous mgmt experience including the hiring, development and coaching of staff
Exceptional communication skills written and verbal; able to present in public forums
Experience and demonstrated ability to read and understand complex documents

Manager Appeals Resume Examples & Samples

Knowledge of CMS regulatory guidelines (i.e. Chapters 13 and 18). Works with Compliance/ Regulatory Affairs and Legal teams that support the Government business units for interpretation of guidelines to resolve member appeal issues
Strong understanding of benefit operations functional areas that have an upstream/downstream impact
Develop working relationships with internal business partners for problem resolution purposes
Works closely with Legal, Compliance and Regulatory Affairs
Identify process gaps and lead process improvement activities
Proactively manage inventory, overtime, and throughput
Four year College Degree with strong preference for advanced degree
Strong communication and presentation skill set with the ability to present data to all levels of the Executive team across Government Claims and Benefit Operations
Experience in appeals and grievances capacity
Experience in dealing with Medicare products and services
Strong problem resolution skill sets with the ability to manage conflict in a professional and productive manner with stakeholders and team members
Advanced written communication skills including grammatical composition and spelling
Available to work flexible work schedules and work extended hours including weekends on a consistent basis in order to meet CMS deadlines
Strong analytical and root cause skills with previous experience in driving process improvements
Ability to ask appropriate questions and actively listen to identify underlying questions and issues (root cause analysis)

Manager of Appeals & Grievances Resume Examples & Samples

Manages staff responsible for the submission/resolution of member inquiries, appeals and grievances for the Plan. Ensures resolutions are compliant
Proactively assesses and audits business processes to determine those most effective and efficient at resolving member problems
Maintains call tracking system of correspondence and outcomes for member appeals/grievances; oversees monitoring of each member submission/resolution to ensure all internal and regulatory timelines are met
Min. 4 years experience in healthcare claims review and/or member dispute resolution
Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient / Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG / RCC pricing)

Manager, Grievance / Appeals Resume Examples & Samples

Requires 3-5 years leadership experience in grievance & appeals, claims or customer services in the healthcare industry; or any combination of education and experience, which would provide an equivalent background
Clinical license preferred
Facets, Maccess, Pega experience preferred
Medicaid knowledge preferred
LTSS service coordination experience preferred

Manager, Medicare Advantage Appeals Resume Examples & Samples

Maintain consistent and open lines of communication with internal and external customers; including facilitating informational and education meetings. Seek always to communicate changes in processes and programs order to enhance a share vision and mission. Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external customers
Twenty-four hour accountability of Medicare Advantage Appeals; including assuring the development of teams which are focused on exceeding the identified objectives through the following: team building sessions, team work facilitation, committee opportunities, and leadership opportunities
Coordinate and implement processes which require and enhance staff accountability by providing direct reports and staff with guidance and educational tools in order to assure compliance with departmental audits. In collaboration with other units and divisions, establish guidelines that quantify measurable care management value, benefit, and outcomes
Identify, develop, and implement division/department projects which are focused on quality, utilization, process and/or outcome improvements. Identify industry benchmarks through scientific research and literature searches on order to assure Medical Management & Policy exceeds industry standards
Develop new policies, procedures and workflows, and revise existing policies, procedures and workflows in order to ensure the efficient and effective operations of the Medicare Advantage appeals process. Develop and implement action plans designed to achieve and enhance compliance to accreditation standards. Work in concert with all corporate divisions and departments to develop strategies supportive of the corporate mission and vision and strategic plan
Actively involved in MM&P and MA Appeals operational performance in relation to monthly STARS results. Critical responsibility to achieve maximum STARS ratings which has financial impact to Highmark, Inc is to conduct tracking, trending and process improvement for operational processes that impact STARS performance
Conducts all auditing activities for assigned area; trends appeals and facilitate meetings to review data for process/product improvements
Collaboration with interdepartmental work groups i.e. Compliance and Quality, Operations and Physician Advisors
Collaboration with Highmark’s Provider Network
Collaboration within interdepartmental work groups i.e. Care Management Systems, Provider Services, Medicare C&D Compliance, Pharmacy, Quality Improvement, Product staff, Provider Reimbursement and Contracting
Ability to interact with external customers and providers
Ability to analyze data, measure outcomes and develop action plans
Highly effective interpersonal skills
Ability to intervene in crisis situations and multi-task
Excellent computer and software knowledge and skills
Demonstrate proficient Project Management skills

Appeals Manager Resume Examples & Samples

Provide expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims
Manages and is accountable for professional employees and/or supervisors
Impact of work is most often at the local level
Flexible and able to adapt to change
Ability to build professional relationships

Appeals Manager Resume Examples & Samples

Oversees the unit and staff members reviewing disability and workers compensation claims; guides staff through appeals process; supports the appeal process by partnering closely with Legal and external vendor partners
Identifies continuous quality improvement measures through appeal result analysis while partnering with the operations team ensuring best practices are met
Makes recommendations on training needs; develops training curriculum; and provides training and one-way coaching as needed
Monitors changes to the ERISA legislation; incorporates workflow changes into the process as defined in legislative changes
Ensures effective process management; ensures accuracy of final customer deliverables resulting in reduction of errors, increased productivity and customer satisfaction
Gathers, prepares, and monitors operations and financial statistical data for reporting provided to the client
Participates on client calls as required
Ensures appropriate and timely handling of legal and client remands; handles client escalations with timely and appropriate resolutions
Ensures appeal requests are managed timely6 and follow the ERISA regulations or client plans; ensures accurate appeal decisions are made by the appeals specialists
Identifies areas to minimize risk of fines, penalties, or errors and omissions
Ensures accurate communications are sent to employees, clients, and attorneys
Administers company personnel policies in all areas and follows company staffing standards and training recommendations
Interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions
Excellent knowledge of disability claims management practices
Knowledge of ERISA regulations
PC literate, including Microsoft Office products
Leadership/management/motivational skills
Ability to meet or exceed Performance Competencie

Manager of Denials & Appeals Resume Examples & Samples

Collaborates with Finance, revenue cycle personnel, physicians, contracting team, case managers, and payers to appeal denials and mitigate trends
Keeps up-to-date on issues surrounding commercial and government payer regulations and processes around audits and denials, and implementing policies and procedures to assure compliant and accurate billing practices
Oversees case management team with maintaining open communication with payers and negotiating concurrent billing status reflective of patient level of care. Jointly maintains with Finance the tracking of denials, the level in the appeals process for each claim, financial impact of outcome of denials, reason for the denial and the upheld and overturned decisions
Responsible for analyzing and interpreting trends associated with denials and appeals to effectively manage reimbursement and build strategies for mitigating future denials
Generates reports of denial activity on a monthly basis with analysis of data and significant trends to the leadership team Perform retrospective record reviews providing clinical updates to insurer in a timely manner. Utilize written and verbal exchange of clinical information for the purpose of providing clear, unambiguous clinical review to payer
Facilitate communication between attending physician and medical advisor to insurer, when this level of communication is indicated to avoid authorization denial
Serve as a resource to Finance, Patient Access, Coding, Patient Accounts and various clinical departments in clarifying hospital status for specific accounts. Stays concurrent on and provides education on regulatory changes as it relates to level of care determination, discharge planning, and appeals and denials
Perform retrospective record reviews providing clinical updates to insurer in a timely manner. Utilize written and verbal exchange of clinical information for the purpose of providing clear, unambiguous clinical review to payer for purposes of payment determination
Perform prebill audits on all inptatient stays that do not meet the 2 midnight rule and assure the proper level of care. Notify finance of outcome of audit
Develop and track indicators and report trends to Director and CFO. Provide feedback to department regarding changes in third party expectations as well as any trends in denial activity
Perform other duties as assigned. Display flexibility, cooperation, characteristics of a team member and excellent communication skills
Registered Nurse licensed to practice in the Commonwealth of Massachusetts required
Bachelor's degree in Nursing or Healthcare field required
Experience with third party claim resolution processes including denials and appeals management, adjudication of claims required
Experience with interqual or millimen criteria required
Knowledge of ICD-10 coding methodology
Relevant management experience or experience in presenting issues, outcomes and recommendations to Senior managers of an organization
Positive attitude, pleasant, professional demeanor with patients, physicians, fellow employees and insurance representatives
Ability to work independently and effectively in a fast paced environment
Ability to work productively in a stressful environment and effectively handles multiple projects and changing priorities
Flexibility in a fast changing environment and able to perform as a team member

Manager, Denials & Appeals Resume Examples & Samples

Ensure that all denials and appeals are processed in accordance with Federal, State and NCQA time frames and other contractual legal requirements
Identify trends within denials and appeals and provide results to internal committees, CMS and the State as required by contract
Serve as the point of contact for any issues or questions related to denials and appeals for various external agencies, including state, local and federal governments, local community and the public
Integrate federal and state law changes to denials and appeals into company's regulatory system
Recommend solutions and ensure issues are corrected and corrective measures are implemented to prevent recurrence
Ensures that all internal and external audit indicators are met
Timely and consistently reports project status to upper management/leadership
EDUCATION, SKILLS & EXPERIENCE

Manager, Medicare Appeals & Grievances Resume Examples & Samples

Direct the daily Medicare appeals and grievance activities to ensure best in class resolution and service as well as ensure compliance with policies, procedures and regulation; includes managing assigned member appeals and formal complaint cases from documentation through resolution
Coach, develop, and mentor staff in the accurate and timely management of Appeals and Grievances providing on-the-spot technical support and direction
Supervise and partner with the Medicare Advantage Appeals and Grievances Business Compliance Lead to ensure compliance with CMS
Assist in new hire and ongoing training programs and ensure Appeals and Grievance staff are knowlegable of policies and procedures
Ensure timely communication with Director on any issues having the potential to impact operation or organization
Serve as liaison and lead resource for both internal and external customers while building positive working relationships
Coordinate and participate in CMS and non-CMS mock auditing and data collection activities as needed

Grievance & Appeals Manager Resume Examples & Samples

Manage work to produce customer value by planning and forecasting, setting objectives and priorities, establishing goals, clarifying accountabilities, assigning work and utilizing management and financial controls
Manage inventory levels, identifying risks and opportunities to improve efficiency and timeliness outcomes
Develop quality controls to ensure Grievance and Appeals workloads are accurately resolved in accordance to CMS guidance
Manage levels of performance and assist with employees’ professional growth by planning and building an effective organization; communicating effectively; coordinating with others; maintaining employee morale; motivating, recognizing and rewarding others; coaching and developing others; managing performance and engaging in self-development
Manage business and public relationships and situations to obtain better business outcomes; communicate effectively and coordinate with others
Effectively drive change and execute on set priorities; set policies and procedures and manage creativity and innovation
Typically has shared responsibility for budget at the cost center level

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